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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_lowvision.pdf
May 01, 2017 - Studies Toolkit Definitions
CASE STUDIES
AHRQ Safety Program for Perinatal Care
Click to read each … case study. … Instead, they set a collaborative and helpful
tone: “We want to improve how we do things around here … ; according to unit staff, the policies
are now internalized as “how we do things around here.” … That’s how
we do it, a little bit at a time.”
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_fullcolor.pdf
May 01, 2017 - Studies Toolkit Definitions
CASE STUDIES
AHRQ Safety Program for Perinatal Care
Click to read each … case study. … Instead, they set a collaborative and helpful
tone: “We want to improve how we do things around here … ; according to unit staff, the policies
are now internalized as “how we do things around here.” … That’s how
we do it, a little bit at a time.”
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/implementing-automatic-referral-resource-guide.pdf
November 16, 2022 - “Case Study: Self-Referral of Patient to a Cardiac Rehabilitation Program, Massachusetts
General Hospital … “Case Study: Referral of Patient to External Cardiac Rehabilitation Program, Massachusetts
General Hospital … The case study includes examples of fax cover sheets and other
forms used to facilitate these referrals … This case study provides screenshots of “nudge” alerts and dashboards that track eligible
patients. … timestamp=1525103139064
This case study summarizes efforts by NYU Langone Health to establish a system-wide
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psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors
December 01, 2009 - The goal is to have a better understanding of how and why people react the way they do and, through this … resulting in either termination of employment or suspension of staff privileges (see Case Study ). … Case Study
Back to Top
(Go to case study citation in perspective)
One organization was having a … RW: How do you do this across disciplines? … August 25, 2011
Understanding safety culture in long-term care: a case study.
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www.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/customer-service/strategy6q-custservice-standards.html
March 01, 2020 - Case Study
References
Download Strategy 6Q:
Standards for Customer Service
(PDF, 708 KB … Rather, they are reminders of the minimum that staff can do to create a positive experience for members … Simply put, scripting:
Conveys the message of your culture: "This is how we do business around here … What can I do to help?" … Case Study
Based on an analysis of CAHPS data as well as other data, Harvard Pilgrim Health Care designed
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psnet.ahrq.gov/issue/do-nurse-and-patient-injuries-share-common-antecedents-analysis-associations-safety-climate
February 29, 2012 - Study
Do nurse and patient injuries share common antecedents? … Do nurse and patient injuries share common antecedents? … Do nurse and patient injuries share common antecedents? … cross-sectional case study of puncture/laceration. … May 20, 2009
How will we know patients are safer?
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-case1.html
November 01, 2014 - Improving Care Delivery Through Lean: Implementation Case Studies
Case 1. … Studies
Introduction to the Case Studies
Case 1. … in the Introduction to the Case Studies. … To develop this case study, we conducted 67 interviews with a total of 65 individuals. … , using Lean principles; this project is presented in a separate case study.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/partnering-2.pdf
May 01, 2016 - How will it help me?
With a PFAC, providers, patients, and staff work in
partnership. … How can I get started? … Why should I do this? … “PFAC helps because it keeps pushing new things
forward—what is the best way to do this? … For a full case study on PFACs, see the Agency for Healthcare Research and Quality,
http://www.ahrq.gov
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psnet.ahrq.gov/issue/decision-support-tools-systems-and-artificial-intelligence-cardiac-imaging
October 19, 2022 - Discussing how artificial intelligence can be utilized to inform diagnostic decision making and improve … February 10, 2021
To tell the truth, the whole truth, may do patients harm: the problem … A case study from a large metropolitan healthcare trust. … April 13, 2017
Do telephone call interruptions have an impact on radiology resident diagnostic … August 3, 2016
Clinically missed cancer: how effectively can radiologists use computer-aided
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www.ahrq.gov/hai/tools/mvp/modules/cusp/build-business-case-slides.html
February 01, 2017 - Present your initiative in a way meaningful to financial leaders. … Slide 9: What Do We Need To Do?
Improve patient and family experience. … Build a business case to prepare for these questions. … Slide 14: Focus for Business Case
What do financial stakeholders focus on? … Slide 26: Making the Pitch
How should you present this to your CFO?
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.146_slideshow.ppt
March 01, 2007 - Note for speaker: examples of how to minimize interruptions in drug delivery zone: This can be done by … either moving medication storage to a quieter location or creating some type of “Do Not Disturb” signage … of disciplinary action
Perception that management would take no notice and was not likely to do anything … How to Improve Reporting:
Create a Culture of Safety
Caregivers must feel safe from undeserved disciplinary … Committed to Safety: Ten Case Studies on Reducing Harm to Patients.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/webinars/webinar5_pu_riskassesst-tools.pdf
January 01, 2012 - develop
pressure ulcers
• Different components of risk for pressure
ulcers
7
When To Do Risk … • If a category falls
between two numbers,
choose the lower score.
12
How To Interpret Braden … 28
Case Study Braden Scale Scores
4
4
2
3
3
3
19 29
Selected Care Planning Examples
Plan … Scale
How To Score Risk Factors
How To Interpret Braden Score
Limits of Risk Scores
Comprehensive … Study
Case Study Braden Scale Scores
Selected Care Planning Examples
Today We Talked About
Any Questions
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psnet.ahrq.gov/issue/morphine-overdose-error-propagation-acute-pain-service-une-surdose-de-morphine-resultant-de
January 13, 2016 - The authors provide a case study involving patient-controlled analgesia (PCA) pump errors that contributed … They discuss how the case illustrates that small mistakes can combine to create major problems. … August 5, 2008
A Guide to Patient Safety in the Medical Practice. … February 20, 2008
To Do No Harm: Ensuring Patient Safety in Health Care Organizations … April 29, 2018
New technology, new errors: how to prime an upgrade of an insulin infusion
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/case-management_executive.pdf
January 01, 2013 - In the context of chronic
illness care, they are central to the role of a case manager,
but a case … We
aimed to define and identify a subset of CM models
representing a sizable category of CM that is … evidence base does not permit defining how
to identify such patients. … CM programs that focus on
clinical guideline measures for care of dementia do increase
adherence to … , experience,
and personality of the person delivering the intervention.
14
Understanding how much
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psnet.ahrq.gov/issue/positive-deviance-different-approach-achieving-patient-safety
May 15, 2024 - Positive deviance: a different approach to achieving patient safety. … Highlighting how positive deviance has demonstrated an encouraging effect on hand hygiene compliance … Positive deviance: a different approach to achieving patient safety. … case study of department leaders in nursing homes. … April 21, 2015
From harm to hope and purposeful action: what could we do after Francis
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/lab-testiing/lab-testing-casereport.pdf
September 05, 2017 - of examples and case studies describing how
practices have applied each component of the toolkit. … 2) How does this practice typically do quality and process improvement?
a. … How do staff communicate with them? … How/why is this person qualified to do this task? … How/why is this person qualified to do this task?
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Nemeth.pdf
January 01, 2002 - How do the users
accomplish programming tasks within this structure? … How do existing incident
reports help to describe adverse events in terms of infusion device programming … circuitous routes to do it. … As a result,
variation in total keystrokes had little to do with user performance. … How do operators know how to make the
device work?
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psnet.ahrq.gov/issue/anatomy-incident-disclosure-importance-dialogue
February 20, 2012 - This detailed case study discusses a unique incident disclosure process that involved prolonged dialogue … Download Citation
Related Resources From the Same Author(s)
What do … October 21, 2011
Patients' and family members' views on how clinicians enact and how … November 17, 2014
The contribution of nurses to incident disclosure: a narrative review … March 23, 2011
Reengineering hospital discharge: a protocol to improve patient safety
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psnet.ahrq.gov/issue/creation-root-cause-analysis-and-action-rca2-standard-work-multidisciplinary-team-prevent
October 19, 2022 - Creation of root cause analysis and action (RCA2) standard work by a multidisciplinary team to prevent … sentinel event: a qualitative case study. … November 29, 2023
Psychosocial processes in healthcare workers: how individuals' perceptions … conflicts: review of case reports from a national Veterans Affairs database. … April 20, 2011
WebM&M Cases
Do Not Disturb!
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psnet.ahrq.gov/web-mm/case-mistaken-intubation
July 01, 2016 - This case provides an opportunity to discuss how to optimally transmit wishes for life-sustaining treatments … the data-sharing agreements that first must be forged to do so safely. … State registries do not cross state lines, while patients often do. … health care preferences and how to ensure those wishes can easily be transmitted across health care … Ideally, the original hospital team would have been aware of how to upload his POLST, and this would